Tuberculosis (TB) causes major worries to many people globally as it is one of the most easily transmitted airborne infectious diseases. Globally, TB remains the 13th principal cause of death. It has been estimated that 10 million individuals have been diagnosed, and 1.5 million died due to TB in 2020. In addition, it is alarming that there were 1.1 million paediatric TB cases and 239 000 cases of TB death in 2015. Furthermore, multi-drug-resistant TB emerged as a new public health crisis as the most effective first-line medication rifampicin reported 82% resistant among 558 000 new cases.
Marginalized communities throughout the planet are often significantly facing health problems, especially from contagious diseases, including TB, because of a hindrance in accessing health-care services and other social and economic determinants. When there is an outbreak of a particular disease in a low- and middle-income countries, the health-care system of that country might be overwhelmed, which reduces its ability to cater to endemic diseases such as TB. Any pandemic can further affect the country's economic growth negatively, leading to further weakening of the public health response. There could be cuts in government spending for other activities.
Nevertheless, TB can be transmitted over quite a long distance and prolonged. Human expiratory activities such as speech, coughing, sneezing or re-suspension from surfaces often discharge and promote airborne transmission. Airborne diseases are easy to spread, nonetheless difficult to be prevented.
An increase in immigrant workers or even tourists and refugees from the profoundly affected countries with TB, causing this issue to become an international concern, particularly in Eastern Europe and Asia. TB has appeared as a public health concern in Malaysia. Multiple studies reported that 25 173 TB cases were recorded all over the country, and World Bank revealed the incidence rate of 92 cases per 100 000 populations in 2019. The top cause of death in Malaysia in the early 1940s and 1950s, the National TB Control Program was introduced as a vertical programme in 1961, about 10 years after the availability of TB chemotherapy. The activities were expanded from the Pusat Tibi Negara (National TB Centre) as the primary referral center for TB to peripheral health clinics and hospitals in 1995. However, the notification and mortality rate for TB in Malaysia was noted to be increasing from 1990 (61 and 4.2 cases per 100,000 populations, respectively) to 2015 (79 and 5.5 cases per 100,000 populations, respectively). Hence, the national strategic plan for TB control was implemented for 2016–2020 with the target set for 2030 and 2035. Globally, the TB control programme aims in line with the WHO goals to eliminate TB by 2050.
In this context, this knowledge, attitude and practice (KAP) study aim to assess the KAP related to TB and its prevention, whether the demographic factors are associated with the level of KAP, and if there is any relationship between the level of KAP related to TB among the undergraduate (UG) students of a public university on the East Coast of Malaysia. All of the students in this study were Malaysians. They came from all over Malaysia and not necessarily from the East Coast of Malaysia itself. Students of a public university were chosen as the study population to shape the future generation; hence, their KAP regarding this re-emerging but entirely forgotten disease is vital to be assessed.
Knowledge, attitude and practice related to tuberculosis
Researchers have done several studies on the KAP related to TB, such as among the final year students in Yazd in central Iran, among the general practitioners in Korea and Delhi, India, and among the community in Kajang Selangor, Malaysia. These studies mostly showed that the respondents or participants had moderate to high knowledge related to TB. However, some respondents indicated a reasonable attitude and low to moderate practice associated with controlling and preventing tuberculous disease management. At the community or public level, delayed treatment-seeking for the symptoms suggestive of TB arises from inappropriate healthcare-seeking habits can be shaped by a socio-economic factor such as poverty, which leads to the financial burden of the diagnosis and treatment on patients, or the issues with the healthcare systems itself, such as poor patient-healthcare providers communication, lack of equipment and drugs, also unprofessional conducts and lack of confidentiality by the healthcare providers.
MATERIALS AND METHODS
This study was conducted in one of the public universities on the East Coast of Malaysia. The participants of this KAP study were among the UG students from all the faculties in the selected university, namely the Faculty of Medicine (FOM), Faculty of Pharmacy (FOP), Faculty of Dentistry (FOD), Faculty of Allied Health Sciences (FAHS), Faculty of Nursing (FON), and Faculty of Science (FOS). The design for this KAP study was a cross-sectional study, following the creation of a previous study. The sample size calculation in this study used the single proportion method, where 0.05 was used as the proportion in the population. The confidence interval (CI) was set at 95%, and the precision used was 0.04. This study targets 40 participants from each faculty which made the total of participants in this study was 240 participants. This study used the convenience sampling method. It was chosen because the data could be collected from anonymous and voluntarily participants who were willing to participate in this study. The data collection of this study was done by manually distributing the questionnaire to the willing participants. They were given 10–20 min to sign the consent form and answer the questionnaire. The total questionnaire distributed to the participants was 240 sets, and 200 sets of questionnaires were returned with complete answers to be analysed. The UG students are aged 20–25 years old.
The study instrument development
The questionnaire was developed from several earlier published studies. It was designed in English because it is the medium used in the selected public university. Experts assessed and verified the content validity qualitatively through several discussions and corrections on the questionnaire drafts. The face validity was checked to ensure the understandability of the questionnaire. In the scoring for Part B, two points were given for correct answers, one point for not specific options, and zero points for any wrong answers. Part C focused on the attitude of the participants towards TB where they were assessed on a 5-point Likert scale type: 'strongly disagree' (1 point), 'disagree' (2 points), 'not sure' (3 topics), 'agree' (4 issues) and 'strongly agree' (5 points) for positive statements and reverse scoring for the negative opinions. Whereas in Part D, questions on practices toward prevention and control of TB used 'always' (4 points), 'often' (3 points), 'seldom' (2 points) and 'never' (1 point).
The questionnaire consists of four parts arranged as Part A, B, C and D, with 93 questions in total. Part A was on the participants' demographic characteristics, including gender, age, faculty, year of study, and whether the participant had had previous or current TB treatment. Part B of the questionnaire focused on the knowledge of the participants on the TB disease itself: Whether they have heard about TB, the sources of their information, and questions on the knowledge, including the symptoms, causes, transmission, and the test used to detect TB, also questions regarding the treatment of TB and drugs used to cure TB. The options of answers for the questions in Part B were 'true', 'false' or 'not sure'. Part C concentrated on the participants' attitude toward TB, including their perception of the seriousness of the TB threat, their belief and opinions on ways to prevent and control the spread of TB, and their perspectives on the role of the public in controlling it TB. These 17 questions on the attitude towards TB were assessed on a 5-point Likert type scale of 'strongly agree' to 'strongly disagree'. The last part of the questionnaire addressed the practice towards prevention and control of TB. Questions were mainly on the proper etiquette of coughing and sneezing and personal health care in controlling TB and its preventive measures. 'Never', 'seldom' 'often' or 'always' were used as the response options.
The SPSS version 22 (IBM, Armonk, NY, United States of America) was used to analyse the data. The categorical variables were described using the frequency and percentage for each category of the sociodemographic data and KAP items. Independent samples t-test was used to compare the KAP scoring between the two separate groups of male and female participants. In comparison, the non-parametric Kruskal–Wallis test was used to compare more than two groups of faculties and years of study due to the small number of participants in some of the groups. The correlation test was used to find the association between two numerical variables of age with the KAP scoring and between the KAP scoring themselves. The statistical significance level was set at 0.05 for a 95% CI.
This study was conducted after obtaining approval from the FAHS Postgraduate and Research Committee (Reference No.: IIUM/310/G/13/4/4-199. Date 6 April, 2017). The information of the participants was kept confidential, and the participants were recruited with their written consent.
Socio-demographic characteristics of the participants
Out of the 200 participants involved in this study, <½ were male (n = 90, 45%). The mean age was 23.3 years old (standard deviation = 1.164). Most of the participants were from the FAHS with a total of 57 (28.5%) participants, followed by the FOM (40, 20%), and each the FOP and the FOD contributed to 35 (17.5%) participants, respectively. The majority of the participants were from the year 4 of the study, with 119 (59.5%) participants. Only 1 year 5 students (0.5%) from the FOM responded to this survey. Five of the participants had received previous or current treatment of TB (2.5%). Table 1 summarises the data obtained for Part A, namely the demographic characteristics of the participants involved in this study.
Knowledge, attitude and practices related to tuberculosis
Knowledge related to tuberculosis
Almost all participants had heard about TB before, except for two (1%) of them unsure of the answer. Among the 200 participants, 90.5% (n = 181), 68% (n = 136), 65% (n = 130), 63% (n = 126), 59.5% (n = 119) and 52% (n = 104) of them mentioned that their source of information on TB was the internet, doctor, newspaper, school, television and educational poster, respectively. The least source of information reported was from the family members (41%, n = 82), radio (27%, n = 54), magazines (26.5%, n = 53), and others (lectures, journals, friends or books) (13%, n = 26). The participants could tick more than one answer for the source of information on TB. Table 2 summarises the participants' answers for Part B, namely on the knowledge regarding TB.
There are seven positive statement questions on the transmission of TB; through the air, sneezing, coughing, singing, speaking, laughing and spitting. Most were aware that TB could be transmitted through the air (92%, n = 184), sneezing (89.5%, n = 179), coughing (93%, n = 186) and spitting (46%, n = 92), but only 24% (n = 48) participants knew that singing is one of the transmission methods of TB infection.
The scores on knowledge related to TB had been divided into three poor categories (1–46), moderate (47–92), and good (93–138). Most of the participants (96%, n = 192) were in the total scores of moderate knowledge level, while only 1 (0.5%) and 7 (3.5%) of the participants were in the poor and good knowledge level, respectively.
Attitude related to tuberculosis
Most of the participants (65%, n = 130) opined that TB is a severe illness. The details of attitude scores are depicted in Table 3. According to the categorisation of poor (1–28), moderate (29–57) and good (58–86), none of them scored poorly for the attitude on TB, whereas 3.5% (n = 7) was categorised in the moderate level. Almost all of them (96.5%, n = 193) scored well.
Practices related to tuberculosis
The prevention of TB infection is mostly on personal preventive measures where most of the participants always covered their mouth and nose while coughing or sneezing, with 59.5% (n = 119) and 54.5% (n = 109), respectively. Details of the practice scores are depicted in Table 4. The total scores were categorised into poor (1–9), moderate (10–19) and good (20–28), where more than half of the participants (56%, n = 112) were at a moderate level. In comparison, the other 44% (n = 88) achieved a good practice status towards the prevention of TB. None of them was grouped into the poor practice level.
The factors associated with the knowledge, attitude and practice regarding tuberculosis
This study explored the association between the KAP scores related to TB with gender, age, faculties and years of study. In the comparison of the KAP scores between male and female participants, no significant difference was found for knowledge (P = 0.985), attitude (P = 0.054) or practice (P = 0.684) [Table 5]. There was no association between the KAP scores and age, where the P values from the correlation test for KAP were 0.919, 0.444 and 0.988, respectively. When the KAP scores were compared between faculties using the Kruskal–Wallis test, significant results were found for all the three variables, with the P < 0.001 for knowledge and attitude and 0.027 for practice [Table 6].
The further post hoc test showed that the knowledge scores were significantly higher among the FOM and FOD participants than other faculties. In comparison, the participants' knowledge scores from the FOS were substantially lower compared to the FOP and FAHS, but not the FON. For attitude, the scores were also significantly higher among the FOM and FOD participants than the other faculties, except the FON. On the other hand, for practice, the only significant results were that the scores from the participants from the FOM were significantly higher than the FOP, FAHS, and FOS. Otherwise, no other effective results were noted for the post hoc test of the KAP scores between the faculties.
Other comparisons made for the KAP scores were between the different years of study, where the 1 year 5 student has combined with the year 4 students as the 'final year'. However, the Kruskal–Wallis test results showed no significant difference in the KAP scores between any years of study with the P values of 0.119, 0.149 and 0.649 for KAP scores, respectively; hence the post hoc test was not indicated.
The relationship between the knowledge, attitude and practice related to tuberculosis
The Pearson correlation test was done between the knowledge with attitude and practice scores and the attitude and practices scores. The total scores for each variable were used to assess any relationship between the variables. The relationship between expertise with attitude and practice scores was statistically significant, with P < 0.001 and 0.045, respectively. The r-values of 0.345 and 0.142 showed a reasonable positive correlation between knowledge and attitude but little positive correlation between knowledge and practices scores. The positive correlation means that when the knowledge scores were high, so were the attitude and practice scores. Nevertheless, the relationship between the attitude and practices scores (P = 0.084) was not statistically significant. Thus, there was no correlation between attitude and practice scores.
Knowledge, attitude and practices related to tuberculosis
This study shows that participants' overall knowledge of TB was satisfactory as 96% scored moderately. This is similar to the research done in the community in Kajang, Malaysia. These knowledge levels are considered low compared to another study done in Yazd, Iran, and in Southern Ethiopia, where 64.8% and 59.8% of the participants scored the high level of knowledge regarding TB among their final year students and high school students, respectively. However, the questionnaires and scoring used might be different. However, this finding is better than a study done in Kudat, Malaysia, where most participants' scores were insufficient knowledge about TB. Almost all of the participants in the current study claimed that they had heard about TB, similar to a prior study where 90.5% of the participants had heard about it.
The majority of the participants in the current study chose the internet as their source of information, followed by doctors, newspapers and school lessons. This is quite different when compared to a study done in India among practicing doctors where most of them preferred journals (58.3%), textbooks (45%), medical representatives (40.6%), also medical conferences (39.5%). Effective information medium is needed to promote awareness and knowledge about TB for the community or public to better understand it, depending on the area, either urban or rural, and the type of medium preferred by them. This is because some of the participants might be aware and claimed that they knew about TB, but they did not have a good understanding of what TB is. Supported by a previous study conducted in South Africa, 96.4% were aware of TB, similar to the situation in Japan where most of them answered correctly on the fundamental questions. Most of them in Korea admitted that they knew and heard about TB, but they were confused and misunderstood specific TB basic concepts upon answering the survey.
The cause of TB infection is a bacterium called Mycobacterium tuberculosis that commonly affects the lungs. In this research, about 80% knew that bacteria cause TB. In contrast, studies were done in Selangor and Sabah showed that only 70.3% and 50.8% answered correctly on the causative agent of TB, respectively. Most of the participants in the current study knew that TB is transmitted through the air, similar to the studies done in Ethiopia and Malaysia. The other modes of transmission of TB, such as sneezing and coughing, were also known to the majority of the participants in the current study, but not the other modes, such as singing, speaking, laughing and spitting.
Regarding the diagnosis of TB, which was asked in general irrespective of the diagnosis for active or latent TB, the participants did well and had good knowledge about it. The participants mainly answered all four TB tests, namely the blood, skin, sputum tests and X-Ray. This is different from previous research, where only 50% knew TB could be detected through a blood test, and only 30% knew that sputum culture was one of the methods of detecting TB infection. Specifically, for active TB where the infection is mainly in the lung, it can be diagnosed from a chest X-ray or by detecting the acid-fast bacilli of the mycobacterium TB through sputum evaluation either directly or from culture, or using a newer technique of nuclear amplification. On the other hand, latent TB infection can be diagnosed through the tuberculin skin test or blood test, with an additional chest X-ray if either one test is positive.
Regarding the Bacille Calmette-Guérin (BCG) vaccination, only 20% of the participants answered that they strongly disagree that BCG vaccination has no contribution to preventing TB. At the same time, about one-third were not sure about this statement. Similar to a study in Hunan, China, the percentage of the final year medical students knowing the benefit of BCG vaccination was only 25.5%. A study among the final year students in Iran also resulted in insufficient knowledge regarding the contribution of BCG vaccination in the prevention of TB, where only 36.1% of them gave the correct answer.
The participants' attitude in this study was quite impressive as 96.5% of them scored a good attitude towards TB. This finding was much better than previous studies where most of the participants in Selangor and Iran scored moderately and had low levels of attitude toward TB. Many participants in the current study were unsure whether closing all the windows could prevent the further spread of TB infection. In reality, proper household ventilation is needed to remove the contaminated air and control the source of infection. Hence, ventilation is a primary type of environmental control to prevent the transmission of TB.
In this study, the level of practice of the participants towards the prevention of TB was moderate (56%), relatively low compared to a study in Iran where 44.75% scored a high level of practice. More than half of the participants always covered their mouth when coughing and covered their nose and mouth when sneezing. However, most of them seldom cover their nose and mouth when they see a person nearby cough or sneeze. The number of participants who never and rarely wear a face mask in a crowded public area or when visiting patients in hospitals, respectively was high. The study was conducted before the start of the COVID-19 Pandemic. However, Iranian students who wore a face mask in the hospital, especially when examining patients, were already high (70.2%).
The factors associated with knowledge, attitude and practice regarding tuberculosis
In the finding of this research, there was no significant difference in the KAP levels between genders, age and years of study of the participants. The studies were done in Selangor and Kelantan also found no significant difference in the KAP levels between different genders. Similarly, two previous studies also showed no association between the level of knowledge regarding TB with the age of the participants. In contrast, there was a significant difference concerning the levels of KAP regarding TB between the different faculties of the participants. This could be due to the faculty participants, such as the FOM and FOD, learning about TB formally.
The relationship between knowledge, attitude and practice related to tuberculosis
The association between the KAP related to TB was also determined in this study. A modest correlation emerged between the knowledge and attitude levels and little correlation between the knowledge and practice of the respondents in this study. This is in contrast to the results obtained from previous research, where the level of knowledge was not associated with the attitude and practice of the participants. This study also showed no correlation between the participants' attitudes and practice levels regarding TB.
Limitation of the study
As with any other research, this study has a few limitations. The cross-sectional study design means that a causal relationship cannot be concluded between the outcome and the independent variables in this study, where only the relationship between variables was feasible. Furthermore, the difficulties in conducting random sampling make the inference of the study results to the population impossible. Given that, further study using a random sampling method is recommended to generalise the results to the study population better.
Overall, the KAP on TB among the UG students in the university was satisfactory as most of them scored moderate and reasonable levels. The findings also showed associations between the KAP scores and the faculties of the participants, where the participants from the FOM had the highest KAP scores regarding TB and its prevention. The findings also showed positive correlations between the participant's level of knowledge on TB with their attitude and practice. Promoting awareness, early prevention, health education programmes through social media such as WhatsApp, Facebook, Twitter, Instagram or Tic Toc, which are famous nowadays, especially to the younger generation, and the betterment of the monitoring system related to TB may be needed to improve KAPs in controlling and preventing TB infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors are much grateful to the students who participated in this research.
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